Acrodermatitis Continua of Hallopeau ?

presented by

Ian McColl MBChB, FACD

Gold Coast, Australia

on April 27, 2005

Consultant Dermatologist, John Flynn Medical Centre, Tugun, Queensland, Australia
 
Abstract An 89 years old lady presented with a 6 months history of painful loss of her large toenails and loosening of some of the others.The fingernails were not involved. Investigations failed to shed any light on the diagnosis. She responded to treatment with topical steroids and Mupirocin ointment under occlusion. A presumptive diagnosis of acrodermatitis of Hallopeau was made.
Patient
P.F., 89-year-old woman
Duration
6 months
Distribution
Toe and Nail beds
History

She gives a 6 month history of a painful eruption involving her nail beds with loosening and loss of the toenails and some of the other nails on her feet.The hands have not been involved. Swabs have been done and the nails have been sent for culture. On one occasion Staph aureus was grown and also candida but on several occasions the swabs have been negative. She has not responded to several courses of antibiotics. There was no family history or past history of psoriasis.
Her nail beds are showing no signs of healing. This lady was sent to me for a second opinion from another Dermatologist who could not make a definite diagnosis
Physical Examination

She had lost both her large toenails. The tips of her large toes were swollen and had layers of pus. Several other toenails were loose and had pus surrounding them.
Images

Fig 1

Fig 2 and Fig 3

Fig 4 showing the big toe after 2 weeks therapy

 

Laboratory Data

Staph and candida had been grown from swabs before I saw her but my swabs for bacteria and viruses were negative.
Histopathology

Biopsy and immunofluorescence showed granulation tissue only and negative immunofluorescence.
Diagnosis Acrodermatitis continua of Hallopeau
Reasons Presented

I started her on a strong topical steroid and Mupirocin creams under occlusion tds. When I reviewed her at one week her nail beds had improved and some re epithelialisation was occurring. She was not taking any other regular drugs.
Questions

She has continued to improve with her topical therapy. Pemphigus vegetans has been shown to present in a similar manner but her negative immunofluorescence and response to topical therapy would argue against that diagnosis. Unfortunately her histopathology did not show the subcorneal pustules you associate with Acrodermatitis of Hallopeau but I do not have any other diagnosis. Any other suggestions?
References
  1. Benjamin E Rosenberg MD, and Bruce E Strober MD PhD Acrodermatitis continua Dermatology Online Journal 10 (3): 9
  2. Torok L, Husz S, Ocsai H, Krischner A, Kiss M. Pemphigus vegetans presenting as acrodermatitis continua suppurativa. Eur J Dermatol. 2003 Nov-Dec;13(6):579-81
  3. PubMed search on Acrodermatitis continua of Hallopeau

 

Comments from Faculty and Members

David Elpern MD, Williamstown, MA, USA on Apr 27, 2005

This is a fascinating case. The localization mostly to the great toes raises the question of external causes - iatrogenic or factitial. This may explain why occlusion was helpful. "Sometimes, it is more important to treat the patient who has the disease than it is to treat the disease the patient has." Dr. McColl's attention to this patient may have done more to help her than the ingredients of the creams prescribed.

Shahbaz Janjua MD, Lalamusa, Pakistan on Apr 27, 2005

Acrodermatitis continua of Hallopeau seems to be a logical conclusion after viewing the clinical pictures and knowing all the test results. Subcorneal neutrophilic (sterile) pustules on histopathology should have confirm this diagnosis especially in the absence of any lesions of pustular psoriasis elsewhere. In both the situations, she would be candidate for an aggressive systemic therapy (acitretin or cyclosporin in my view) if she did'nt respond to the topical therapy alone.

Haitam Alqari MD, New York, NY, USA on Apr 27, 2005

Hi, I guess with this type of presentation, sudden in onset, painful, almost negative cultures specially virus (Herpes simples), this could be a case of bilateral pyoderma gangrenosum. Even though Acrodermatitis continua of Hallopeau can present in this way, but usually painless unless it’s secondary infected. Is the pt smoker? Just to role out Buerger's disease.

Amanda Oakley FRACP, Hamilton, New Zealand on Apr 28, 2005

Lichen planus may rarely present like this. Biopsy of erosive LP is frequently non-specific. I presented a case in 1985 at the Annual Meeting of the BAD, in London - she lost all her nails and was treated with oral steroids for years [OAKLEY A, HARPER J, COPEMAN P. Ulcerative Lichen Planus of the Mouth and Feet. Br J Derm 1985; 113: suppl 29, 63 - 64.]

Khalifa Shaquie MD, PhD, Professor of Dermatology, College of Medicine, University of Baghdad, Baghdad, Iraq on Apr 29, 2005

The picture is more in favour of pemphigus vegetans, Hallopeau type rather than acrodermatitis continua. Please repeat the biopsy from the active clean margin. Give oral steroids which will be beneficial for all differential diagnoses that were mentioned.

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